Chapter 3 - The “pain medicine”

The “pain medicine” 

Nobody likes pain, but it is actually a super-medicine. Like diseases, it is a gift from nature. The “pain” here does not refer to the kind caused in accidents or fights, but the sensation felt when proactively practicing Paida and/or Lajin. Of the various recovery responses, pain is the most commonly experienced. Some may refuse to do Paida and Lajin because of the pain. Actually, it is precisely the reason that they should be practiced.

Pain is the secret weapon of their miraculous healing effects. The reasons are as follows:

Firstly, pain is a tool of precise diagnosis, just as an old saying goes, “where there are no blockages in the meridians, no pain will be felt.” Pain indicates the part of the body where an illness lies; and the intensity of pain indicates the severity of a disease. Patients with heart diseases or emotional problems are more afraid of pain than the average person. Heart diseases refer to disorders in the physical organ, the heart; whereas emotional problems refer to disorders of the intangible psyche, spirit, or mind. Heart diseases and emotional problems are interrelated and mutually influential; they are both manifestations of blockages in the Heart and Pericardium Meridians. If a part of the body where a meridian runs through is hurting, it signals that the corresponding organ is having problems.

“Pain” directly stimulates and opens up the heart, triggers willpower, and mobilizes yang-qi (right qi); it is a “medicine for the heart”. The heart, as sovereign of bodily organs, governs the spirit. It stimulates secretion of bio-chemicals that the body needs, i.e. “endogenous medicine”. Without pain, our self-healing power will not be activated, thus the endogenous medicine will not be produced. Our self-healing ability acts like a compound medicine, and pain is the catalyst that triggers generation of this endogenous medicine. Hence, pain is part of the process of producing endogenous medicine; it may even be an integral part of the medicine itself, i.e. the “pain medicine”. Moreover, pain is also the process of pinpointing the location of diseases so that further treatment can be carried out; it reveals its targets very clearly, i.e. at the area where the pain is felt. Hence, the “pain medicine” is a “precision medicine”; persistent pain means continuous treatment with precision medicine. Moreover, this pain is bearable; it can be self-regulated according to one’s condition and tolerance.

As the “pain medicine” is an “endogenous medicine” manifested as self-healing power, it is more accurate, symptomatic, eco-friendly and direct compared to medication. In Chinese medicine, self-healing power is referred to as yang-qi, or “right qi”; in Western medicine, it is referred to as immunity, repairing ability, hormones, insulin, stem cells, adrenaline, or enkephalin. With the advancement of medical science, new terms will be continually added to the list.

The degree of “pain” is proportionate to the efficacy of this “medicine”, i.e. the more hurting it is, the better the self-healing efficacy. During Paida and Lajin, when more pain is felt, yang-qi rises faster and the entire body immediately warms up and even starts to sweat. The time when most pain is felt is the time when yang-qi is conjured up the fastest; hence the best efficacy is gained. The Qi of diseases is yin-qi (evil qi); when it accumulates, more diseases will break out and life is shortened; on the contrary, when yang-qi is abundant, fewer diseases will break out and life is prolonged. When yang rises, yin will decline. Yang-qi is zheng-qi (or “right qi”), as described in Huang Di Nei Jing, “when zheng-qi is kept in, evils shall not enter”. This sentence sums up the true essence of Chinese medicine.

In case the pain becomes almost unbearable at the early stage of Paida and Lajin, the intensity can be reduced and the duration lengthened.

“Pain” makes us focused. We can experience the state of the body and soul becoming one, the state where giving and receiving is occurring in ourselves. Thus, pain is also a meditation method. During meditation, one may find it hard to concentrate. When you feel pain during Paida and/or Lajin, your mind is unprecedentedly focused; it is impossible at that moment to think about your children, the stock market or other matters. Your thoughts will focus on the part that hurts most, and that is almost invariably where the problems are. The ability to endure pain varies with changing state of mind, and it will be enhanced through continued Paida and Lajin. The ability to endure greater pain is a sign of better health.

“Pain” is our natural protection system that enables us to avoid danger; as such, the “pain medicine” is safer than medication. When the pain exceeds one’s endurance, one will instinctively stop using the “pain medicine”. Beginners, the seriously ill, and the elderly need not start Paida and/or Lajin with high intensity, they also should not anxiously try to gain significant efficacy at one go, but should instead take it one step at a time.

Our ability to endure pain will gradually improve with the increase in intensity and duration of Paida and Lajin. When the tolerance levels for the “pain medicine” and medication are compared, it is found that their effects on the human body are exactly opposite. Greater tolerance of the “pain medicine” indicates alleviation or curing of diseases, whereas greater tolerance of medication implies that the drug has become ineffective, or has even caused side effects.

The “pain medicine” is essentially a “medicine for the mind”; it is the result of interaction between the mind and the body. A person’s attitude towards pain is constantly changing; once you change your mindset and start to view pain as a proactive and positive therapy, you can instantly endure greater pain. Then, pain will no longer be an enemy or a devil, but instead a friend or an angel.

As smooth flowing meridians are considered a nourishing tonic to the body, and pain is the process of clearing meridians, thus the “pain medicine” is considered a tonic as well. 

TAPPING 5 (Tapping on the Diagnosis)

Tapping on the Diagnosis

There are few things more terrifying than going to the doctor for a potentially life-changing diagnosis. In fact, the only thing worse might be actually getting the bad news you’ve been dreading.
Things can get complicated at this point. Very often, the stress and worry that accompanies your diagnosis can have just as big an impact on your overall health as the illness or injury you’re facing. As such, it’s crucial that you find a way to deal with it.

In my book, “The Tapping Solution: A Revolutionary System for Stress-Free Living,” I share many Tapping routines to help you deal with common issues so many of us face, one of them being a script to help you deal with a scary diagnosis. Here, I’m presenting an extended version of that script to help you release the negative swirl of emotions surrounding your health.

Tapping varies for everyone: some people just need to do a few rounds to clear the negative emotions that have them all wound up; others need a few more rounds. Whichever the case is for you, it’s always great to go deeper and longer. As you do, take note of any unexpected thoughts or feelings that arise. These can often be used to help you clear your negative attachment to incidents or emotions buried in your unconscious mind that may have been tripping you up without you even knowing it!


In the book, I recommend starting your Tapping by using a “check-in” phrase to determine if this particular issue is something you need to work on. The check-in phrase for this routine will vary depending on what you’ve been diagnosed with, but it would be something along the lines of I have [name what you’ve been diagnosed with] and there’s very little I can do about it.

Essentially, you want to acknowledge what the doctor says you have. More importantly, you want to address your beliefs surrounding this diagnosis.

How do you feel when you say this check-in phrase? Rate your discomfort on a scale from 0 to 10, with 10 being “absolutely true” and 0 being “not at all true.” If your truth level is a 5 or more, then this is definitely an issue you want to tackle.
 
For this routine, we’ll use a diagnosis of a slipped disc as an example, but make sure to use whatever you’ve been diagnosed with when you’re Tapping. Start at the karate chop point:

Karate Chop: Even though I have a slipped disc, I deeply love and accept myself.

Karate Chop: Even though I have a slipped disc, I completely love and accept myself.

Karate Chop: Even though I have a slipped disc, I totally love and accept myself.

Eyebrow: This slipped disc . . .
Side of Eye: This slipped disc in my back . . .
Under Eye: It’s throbbing and painful . . .
Under Nose: The doctors told me I have a slipped disc . . .
Chin: The doctors told me it would always hurt . . .
Collarbone: The doctors told me it would eventually need surgery . . .
Under Arm: The doctors told me it was degenerating and would likely get worse . . .
Top of Head: The only way the pain goes away is if I take pain medication.

Back to the Eyebrow:

Eyebrow: I believe I’ll have this forever and it will only get worse . . .
Side of Eye: This slipped disc in my back . . .
Under Eye: This painful slipped disc . . .
Under Nose: This throbbing, red-hot pain . . .
Chin: I believe it will only get worse . . .
Collarbone: I believe what the doctors told me about my back . . .
Under Arm: The only way the pain goes away is if I take pain medication . . .
Top of Head: This painful slipped disc.
 
Take a deep breath and check in with yourself. How are you feeling? Rate your feeling on the 0 to 10 scale. Return to the eyebrow. You want to keep tapping until the worry and frustration with your diagnosis has reduced considerably.

Eyebrow: I don’t even know if the medication will work. . .
Side of Eye: I don’t want to get surgery. . .
Under Eye: What if something goes wrong?
Under Nose: What if the surgeons make a mistake?
Chin: I could never afford it. . .
Collarbone: I’m just going to have to live with this pain. . .
Underarm: I don’t want to take medication, but I have to. . .
Top of Head: I don’t know what I’m going to do. . .

Eyebrow: This is going to affect my life in so many ways. . .
Side of Eye: Nothing’s going to be the same anymore. . .
Under Eye: I’m so depressed about this. . .
Under Nose: I can’t believe it. . .
Chin: I just wish I didn’t have a slipped disc. . .
Collarbone: I feel so wounded and weak. . .
Underarm: It’s all downhill from here. . .
Top of Head: I wish I were well again. . .


Keep repeating this routine until your frustration and fear don’t bother you as much. Once you’ve reached a level of calm that you feel satisfied with, move on to the positive rounds below.

Eyebrow: I can fight this. . .
Side of Eye: It means I have some work to do, but I choose to do it.
Under Eye: I’ve been making it much worse in my head. . .
Under Nose: My mood affects how well I feel. . .
Chin: My slipped disc doesn’t have to change my life for good. . .
Collarbone: I can even get a second opinion. . .
Underarm: Even if I have a slipped disc, I might not ever need surgery. . .
Top of Head: I might not need as much medication as I’m thinking. . .


Eyebrow: I need to look after myself better. . .
Side of Eye: I choose to look after myself better. . .
Under Eye: There are different ways I can address my pain. . .
Under Nose: I might consider some alternative therapies. . .
Chin: I might see another doctor. . .
Collarbone: I can deal with this. . .
Under Arm: My diagnosis does not define me. . .
Top of Head: I choose to believe I can heal. . .


Take a deep breath . . . and let it go.

Doctor’s Politics Affect Your Care

Doctor’s Politics Affect Your Care



I already know that this newsletter is going to upset many people--especially those who don't read beyond the title. Everyone likes to believe that their political views are carefully thought out, rational opinions formed by their awareness of the world around them and a mastery of facts. In other words, they are the result of absolute free will and are therefore entirely independent of all other aspects of their lives. Anything that challenges that opinion, which is effectively a challenge to free will, and especially anything that contains the words Republican and Democrat, really upsets people. In other words, anything that even implies that our politics might be influenced by our fundamental psychological or even genetic makeup or, even worse, that our political proclivities might shape how we view the world and the decisions we make, is going to bring out the dogs of war.

But if we are honest about it, we all intuitively know that political beliefs do indeed spill over into nonpolitical domains such as consumer spending, choice of romantic partner, and job hiring. That said, what we're going to talk about today is something quite different but nevertheless touches on the same hot buttons. A new study suggests that the political beliefs of our primary care physicians may predict their professional decisions--at least for certain health questions.1 According to the study, when it comes to politicized health issues like marijuana and abortion, it turns out that a physician's partisan identity is highly correlated with his/her treatment decisions. Because physicians regularly interact with patients on politically sensitive health issues, and because the medical profession is increasingly politicized (e.g., state governments are regulating politicized aspects of medicine), it is necessary to understand how your doctor's political worldviews might impact their decisions, recommendations, and actions in the medical examination room when it comes to your diagnosis and treatment. That understanding should then inform not only how you filter their recommendations but also whether or not it's in your best interest to look for a new doctor.

The political beliefs of our primary care physicians may predict their professional decisions.

So, setting aside the question of free will for the moment, which really isn't being called into question by this study, let me suggest that you read through to the end of the article as there are real lessons to be learned from the several studies we're going to talk about--real lessons that can affect the health care you receive.

With that in mind, let's take a look at the newly released study in question.


Republicans, Democrats, and Doctors

The co-authors of the study, Eitan Hersh, an assistant professor of political science, and Matthew N. Goldenberg, MD, an assistant professor of psychiatry, linked the records of over 20,000 primary care physicians in 29 US states to a voter registration database, thus obtaining the physicians' political party affiliations. They then contacted 1,529 of them to participate in the study, ending up with a sample of 231 doctors--both Democratic and Republican primary care physicians--whom they then surveyed. The survey involved the physicians evaluating nine patient vignettes which they were told were recounted by patients as part of a complete physical. Three of the vignettes addressed especially politicized health issues (marijuana, abortion, and firearm storage). Specifically, the vignettes presented scenarios such as a healthy-appearing 38-year-old male patient who "acknowledges using recreational marijuana three times per week" or "who is a parent with two small children at home" and "acknowledges having several firearms at home." And yet another fictional patient said she had two abortions in the past five years. Those vignettes were interspersed with some more neutral complaints like obesity, depression, or not wearing a motorcycle helmet.

Hersh and Goldenberg then asked the physicians to rate the seriousness of the issue presented in each vignette and how they would treat the patient. The physicians who responded did not know that the survey was about their politics. Rather, they thought it was about how they administer the patient interviews that primary-care doctors give patients before they first treat them. On the politicized health issues--and only on such issues--Democratic and Republican physicians differed substantially in their expressed concern and their recommended treatment plan. (It should be noted that the study controlled for physician demographics like age, gender, and religiosity, patient population, and geography.)

According to Hersh and Goldenberg, "The evidence suggests that doctors allow their political views to influence their professional decisions in the medical exam room. Just as patients choose physicians of a certain gender to feel more comfortable, our study suggests they may want to make a similar calculation based on their doctor's political views." It's important to note that this is not an insignificant issue as physicians frequently interact with patients about politically salient health issues, such as drug use, firearm safety, and sexual behavior.


Perhaps not too surprisingly, Republican physicians expressed more concern than their Democratic colleagues about the vignettes on marijuana use and abortion whereas the Democratic physicians were more concerned about the vignette related to firearms. Democratic doctors were less likely to discuss the health risks of marijuana or highlight its legal risks or encourage the patient to cut down their usage.  On the other hand, they were more likely to urge patients not to store firearms in the home, whereas the Republican physicians were much more likely to discuss the health and legal risks of marijuana and to advise the patient to cut back. They also were twice as likely as Democrats to discourage patients from having more abortions in the future and 35 percent more likely to discuss mental health in connection with abortions. Interestingly, Republican physicians were also significantly more likely to ask their patients if they were storing their firearms safely, though Democrats were more likely to urge them simply not to have them in the home. It should be noted that research shows that counseling by doctors can help promote safe gun storage. On the other hand, studies show that a majority of doctors choose not to go there. Again, physicians of both parties similarly rated the vignettes on non-political issues like depression, alcohol abuse, obesity, and not wearing a motorcycle helmet.



Effect of "Republican" on seriousness of issue. (PNAS)

The study concluded that physician partisan bias can lead to unwarranted variation in patient care. Thus, awareness of how a physician's political attitudes might affect patient care is important to both physicians and patients alike. As Goldenberg noted, "Given the politicization of certain health issues affecting countless patients, it is imperative that physicians consider how their political views may affect their professional judgments. The evidence calls for heightened awareness among physicians and more training concerning our biases in how we address politically salient health issues." As the authors write in the study, "To be clear, we cannot say with any certainty what the root cause of partisan differences in treatment is. However, regardless of the underlying mechanism that affects physician judgment, the evidence suggests a clear effect from the patient's perspective."

In summary, "Just as a patient may seek out a physician of a certain gender to feel more comfortable, the evidence suggests that a patient may need to make the same calculation regarding political ideology." Of course, a Republican or Democratic doctor would likely live in an area where the majority of his or her patients were of the same party. Still, if a contentious health issue is discussed during an appointment, it might be the provider's political beliefs talking, rather than their medical training. In certain cases, according to the study's authors, it might be worth getting a second opinion--perhaps a few towns over.

That said, although I would tend to agree with the study's observations, I'm not sure I agree with their recommendation, at least as stated. But before we go there, let's take a look at the elephant in the room. (And yes, the pun was deliberate.)

The Elephant in the Room

Hersh said he hopes the study will open up a dialogue about how political bias affects medical decision-making and make practitioners more aware of ways in which their personal beliefs might affect the care they give patients. Depending on the study's response, he says, he might even consider making his data on physician names and party affiliations public. This would be important because until the political data can be effectively linked to actual outcomes, the true extent of how politics affect physicians' decisions won't be clear. Unfortunately, he is likely to encounter resistance, especially among the large number of doctors who don't think that their political views inform their practice decisions. As Rep. Phil Roe (R-Tenn.), a retired obstetrician-gynecologist who co-chairs the GOP Doctors Caucus,4 told the Washington Post, "I never once treated a Republican or Democrat cancer in my life. When a patient walked into my office, I didn't know if they were a Republican or a Democrat, and I honestly didn't care."5 Roe went on to tell the Post that he hopes patients will seek out the best care available regardless of their doctor's political affiliation. "Party affiliation should have nothing to do with patient care."

And he is correct. Party affiliation should have nothing to do with patient care. Unfortunately, his pronouncements on the study have nothing to do with the study's actual conclusions. They are a red herring. In fact, the study has nothing to do with Republican or Democratic cancer. All the study is saying is that certain mindsets that are frequently, but not exclusively, associated with party affiliation do have an effect on physician decision making.

In fact, other research has shown that this is even more ingrained than you might think--that there is frequently a genetic factor to political leanings. A study, conducted by researchers out of the University of California, San Diego and Harvard University, identified a particular gene that seems to predispose certain people to a more "liberal" outlook.6 (We will talk more about what a "liberal" outlook actually means in a moment.) Data from more than 2,500 volunteers in the National Longitudinal Study of Adolescent Health was analyzed to compare people with the R7 variant of the DRD4 gene.7 Keep in mind that a person's political bent has always been assumed to be a product of their environment and social background, not their genes. And while environment and background certainly have a large impact on each person's beliefs, this study strongly indicates there is something going on behind the scenes in our DNA that influences us right down to our core values. Research has established that approximately 38% of us possess the R7 variant of the DRD4 gene. And please keep in mind that scientists hasten to add that neither version of the gene is better than the other -- if one were superior, natural selection most likely would have eliminated the inferior form.





Now let's talk about what we mean by "liberal," at least as far as this study is concerned. In fact, "liberal" in this case does not refer to which candidate you vote for but, rather, refers to a penchant for novelty seeking behavior. Earlier studies have determined a link between the R7 variant and novelty-seeking behavior. People with the variant may be more likely to try new experiences and take some risks. In other words, the study is saying that those who are more likely to be comfortable pushing boundaries and trying new things can be defined as liberal. And those who don't, who like to play it safe, can be defined as conservative. And again, neither is superior when it comes to genetic survival. On the one hand, playing it safe could have certainly been advantageous to prehistoric man if wild animals were about. But being willing to try new things and push out into new territory would have been advantageous if food supplies were strained in your familiar environment. Each tendency can be advantageous depending on the circumstances.

In any case, now researchers are applying the new findings to this information and suggesting that when people with the R7 gene variant have also had an active social network, they may be more likely to seek out their friends' opinions on political subjects and be open to a wider range of lifestyles, creating a more liberal position politically. And that's the tie-in to politics. However, having the variant does not guarantee a final resting point on the political spectrum. For example, if either the variant form of the gene is not there or the adolescent years were not socially popular ones, then the person can fall anywhere on the political spectrum. The findings were the same across age, gender, ethnicity, and background differences. The bottom line is that we're only talking about tendencies here. There are indeed conservative Democrats and liberal Republicans (I believe they're called RINO's...Laughing). Again, we're not really talking about politics. We're talking about a fundamental, psychological way of viewing the world that merely gives people a predilection to end up in one party or another--not a guarantee.

In fact, more than half a century of research in genetics, neuroscience, and psychology has demonstrated that human behaviors, including social and political attitudes, are influenced by genetic and neurobiological factors. However, these findings have not been widely accepted or incorporated into the dominant paradigms that explain the underlying causes of political ideology. This has been attributed in part to measurement and sample limitations, as well the relative absence of molecular genetic studies.

In addition, there's the 2012 study that combined evidence from over 12,000 twins pairs, ascertained from nine different studies conducted in five democracies with the data from three genome-wide association studies on political ideology.8 In other words, it was not a small study. It concluded that political ideology constitutes a fundamental aspect of one's genetically informed psychological disposition.

So what does this mean for doctors? Well, let's return to Rep. Roe's statement: "When a patient walked into my office, I didn't know if they were a Republican or a Democrat, and I honestly didn't care." We should now be able to see that this statement is irrelevant. We're not actually talking about party affiliation. We're talking about genetically informed psychological dispositions that can inform how doctors choose to treat certain conditions--not that they differentiate between Republican and Democratic patients. And yes, people of certain dispositions tend to gravitate to certain political parties that support that disposition--but again, that's only a tendency, not a certainty. In any case, those same psychological dispositions tend to lean doctors towards conclusions and treatments in line with that disposition.

But What Does the Mean to Me?

At this point, let's just throw politics completely out the window, which should simplify the discussion and remove the emotional heat from it. Let's just acknowledge that different doctors will vary in:

What treatment options they recommend in certain situations
Where they fall on the risk vs safety continuum
Now things become much simpler, which allows us to establish some physician selection guidelines.

Surgery

When it comes to surgery, there are essentially two kinds: standard and cutting edge, high risk.

For standard surgical procedures, you probably want a conservative doctor who follows the safest protocols available. When it comes to routine surgery, you don't want a risk taker.
For more cutting edge or experimental surgeries, you probably want a surgeon who is comfortable playing in unfamiliar territory. If the surgical technique involved is not routine, you want a doctor who thrives when playing outside their comfort zone.
And by all means, check out your surgeon's rating for the particular procedure you're looking to have them perform. Why in the world would you choose a doctor to operate on you who isn't very good at performing the operation and tends to leave lots of bodies on the operating table? And for that matter, be sure and check out the safety score for the hospital where your surgeon is going to be performing the procedure. They provide your doctor's support team.

Primary Care Treatment

On the other hand, when it comes to general medical diagnosis and treatment, you probably want a doctor who lines up with your view of health and nutrition.

>If you're into herbs and alternative health, find a doctor who is friendly (or at least not hostile) to those protocols. Why would you want to put yourself in a position where you're constantly fighting with your doctor about the medications he/she prescribes or the supplements you want to take?

>If you're a strong believer in the virtues of toeing the medical line, then track down the most medically astute doctor you can find--regardless of their opinion of alternative health.

>If you smoke marijuana or use birth control, find a doctor who doesn't fight you about it or look askance at your lifestyle.

>If you don't believe in antidepressants or any other class of pharmaceutical drugs, then don't go to a doctor who refuses to explore alternative treatments--even alternative medical treatments--with you.


>And, as with surgeons, even when selecting a primary care physician, it's a good idea to check out how the doctors you're looking at rate with previous patients.

If you find that you are with the wrong doctor, don’t hesitate to change physicians. It's your life, not your doctor's.


The bottom line is that when medical skill is the priority, find the most skillful doctor you can find--regardless of political outlook. When looking for a primary care physician who will work with you on an ongoing basis, find a doctor of like mind and similar disposition. And if you find that you are with the wrong doctor, don't hesitate to change physicians. Remember, it's your life, not your doctor's.

Over-diagnosis & Mammography

Over-diagnosis & Mammography 


Radiology Today (click for magazine cover)

June 2012

Overdiagnosis & Mammography 
By Kathy Hardy
Radiology Today
Vol. 13 No. 6 P. 24

A study finds over-diagnosis with increased screening, but there’s no way to determine which tumors do not need to be treated.

As radiologists, oncologists, patients, and advocates continue to wrestle with when mammography screening should begin, a new study suggests that with more views of breast tissue comes more potential overdiagnosis of breast cancer. The study, published in the Annals of Internal Medicine, concludes that mammography screening entails a substantial amount of overdiagnosis, which could lead women to undergo unnecessary and potentially harmful treatments.

Some believe the research casts more doubt on screening mammography, a modality still dealing with an identity crisis in the wake of the US Preventive Services Task Force’s 2009 recommendations suggesting that women at normal risk of breast cancer can reasonably delay mammography screening until they reach the age of 50. However many people in the breast imaging field still recommend mammograms for women at normal risk begin at age 40. The split creates a decision for referring physicians and patients regarding when to start breast cancer screening. Many breast radiologists contend that the idea of overdiagnosis and potentially unnecessary treatment of nonfatal cancer adds to the dilemma for doctors.

“This new epidemiological study tries to show that if we weren’t screening so much, we wouldn’t find as many unimportant tumors,” says Robin B. Shermis, MD, MPH, medical director of Ohio’s Toledo Hospital Breast Care Center. “This study deals in a theoretical world. In practicality, we can’t always tell which tumors have a potential aggressive biology when they are first detected. At initial detection, there is no way to identify whether or not a tumor is life threatening or will become life threatening.”

In blunter words, if you can’t differentiate between the tumors that will progress and kill a woman and the ones that will never harm her, how do you decide which tumors to treat? Breast radiologists assert that it’s too early to discuss what to do when mammography uncovers a tumor that fulfills the laboratory criteria of cancer but, if left alone, would never cause the patient any harm. They contend that, since science cannot accurately predict which tumors are harmless and which are more aggressive, it’s necessary to treat any tumor that's found as if it's deadly. That means surgical removal and sometimes radiation or chemotherapy.

“That’s exactly the problem,” says Rulla M. Tamimi, ScD, an associate professor of medicine at Harvard Medical School and a coauthor of the study. “Through imaging and pathology, we’re unable to determine the difference between fatal and nonfatal cancers. It’s important to have studies like this to get the debate going. Women should know about overdiagnosis.”

Finding Too Much?
The objective of the report, “Overdiagnosis of Invasive Breast Cancer Due to Mammography Screening: Results From the Norwegian Screening Program,” was to estimate the percentage of overdiagnosis of breast cancer attributable to mammography screening. This was done with a comparison of invasive breast cancer incidence with and without screening.

Tamimi says the data from Norway provided a unique opportunity to review data collected during the county-by-county introduction of a breast cancer screening program for women aged 50 to 69 that took place from 1996 to 2005. Researchers analyzed approximately 40,000 breast cancers, comparing cases found in counties where screenings were offered against counties where screenings were not yet offered. The study’s authors found that instances of invasive breast cancer increased 18% to 25% among participants who received screening mammography. They also found that between 1,169 and 1,948 of those women were overdiagnosed and received unnecessary treatments.

“In any screening program, there will be risks and benefits,” Tamimi says. “One of those risks is detecting cancers that, if left alone, will not cause mortality in the population of people screened.”

Carol H. Lee, MD, FACR, attending radiologist at Memorial Sloan-Kettering Cancer Center in New York and chair of the ACR’s Breast Imaging Commission Communications Committee, notes that the Norwegian study findings agree with those of the US Preventive Services Task Force recommendations, which suggested that there is a risk of overdiagnosis based on the number of women screened. However, she’s not suggesting that this means cancers found in breast tissue should be left alone.

“Saying [there is overdiagnosis], I know that screening with mammography saves lives,” Lee says. “The emphasis on overdiagnosis is too great.”

Lee contends that screening mammography shouldn’t decrease just because it may find cancers that are not deadly. “Does it make sense to stop finding cancers because some of them will not go on to be fatal?” she asks. Lee also challenges the use of the term “overdiagnosis,” saying instead that nonlethal breast cancer may be overtreated, not overdiagnosed.

“If a tumor meets the histologic criteria for being malignant, we treat them all as if they’re life threatening,” Lee says. “That’s the trade-off. We can’t tell whether it is life threatening.”

Treat What You Find
Looking at the study’s parameters, radiologist Stamatia Destounis, MD, managing partner of Elizabeth Wende Breast Care in Rochester, New York, questions the validity of the data, noting that “if you want to prove something invalid you can look at the data any way you want.” In particular, she points to the time span used to gather data for this study.

“With mammography, you need to study a program for more than nine years,” she says. “Imaging to detect breast cancer involves identification of subtle findings on mammography over time and long-term follow-up after breast cancer diagnosis to identify long-term benefits. We need more information on the women within the study and the control group over longer periods of time to identify a benefit.”

In her work with the ACR, Lee spends a great deal of time discussing the benefits of breast cancer screening. With the publicity that surrounds studies like this and the task force recommendations, she says referring physicians and women are unsure of what steps they should take when it comes to mammography.

“Another benefit of screening mammography relates to treatment options,” Lee says. “If you have a mammogram, there’s a chance that it will pick up a cancer that will never be life threatening, but you’ll still undergo surgery and possibly chemotherapy and/or radiation. However, there is also a chance that your life will be saved and treatment for the cancer will be less invasive because it is caught sooner. Which would you prefer? Different women will have different reactions.”

One of Lee’s arguments against studies like this and the task force recommendations is that with an epidemiological study you’re dealing with mathematical modeling rather than with actual practice. Shermis agrees that epidemiology has its place when studying breast cancer from a public health perspective. However, while the studies may provide insight to cost factors associated with unnecessary medical procedures and the stress associated with screening mammography follow-ups, they don’t address the human aspect of detecting the disease in women.

“Yes, there’s anxiety associated with any follow-up related to screening mammography findings, but that’s minimal compared to knowing you have a tumor and not treating it,” Shermis says. “An option would never be to leave a cancer alone. In addition, there’s much less stress involved and it’s much less expensive to treat a cancer when it’s small than after it has grown large.”

Confusing Referrers and Patients
Shermis and others believe these study results simply add to the already confusing amount of information disseminated in the past several years regarding screening mammography guidelines.

“This is just more misleading info,” Shermis says. “Women and referring physicians are confused enough. We were just starting to see a bounce back in screening mammography from the backlash that resulted when the task force findings were issued. Now, this study compounds the confusion.”

Identifying cancer is not a perfect science, Shermis notes. However, it is the job of breast imagers, oncologists, and surgeons to follow the proper steps required to make the best educated decision possible when it comes to breast cancer detection and ultimately a course of treatment.

“Nothing’s perfect,” he says, “but when you have the right people involved, it’s a relatively smooth process. Until we can identify cancers, we need to treat tumors that we find. Breast cancer screening has been profoundly successful in saving lives. As long as you have good standards for how to work up cancers and you follow them, you will have success.”

Radiologists, surgeons, and oncologists “all recognize that this tumor may not do anything,” Shermis adds. “None of us could look at a cancer and say we didn’t have to treat it. However, we’ve seen tiny cancers metastasize and large cancers do nothing. We’re not in a position to guess whether or not a tumor could lead to cancer.”

“The continuing dilemma for breast imagers is that we try to be as evidence-based as possible,” Lee says. “We’re not resting on our laurels. Clinical trials done with a half-million women over more than 20 years show us that mammography is still the gold standard for breast cancer screening. We need to stop picking apart the basic finding that mammography saves lives.”

Identifying Dangerous Tumors
Rather than a continued focus on the ethicality of breast cancer screening, Lee suggests that researchers look to finding a way to sort out which cancers have the potential to be lethal and which are safe to leave alone. Tamimi believes that’s where data from the Norwegian study can actually be used to help the evolution of breast screening guidelines. Pointing out instances of overdiagnosis and overtreatment of tumors found in the breast can help researchers determine where to focus next in the process of developing accurate breast cancer detection methods. Advancements in imaging technology and the use of ultrasound and MRI in scanning breast tissue continue to help locate tumors but, in many cases, also increase the incidence of false-positives. But there are other areas where further research could help identify what the technology is finding.

“They need to look at tumor characteristics and tumor markers and learn more about which traits are less aggressive,” Tamimi says.

“Many women aren’t even aware that overdiagnosis exists in breast cancer screening,” she adds. “The discussion started with prostate cancer, but more should be said regarding overdiagnosis in breast cancer. Women are being told they have a cancer, which comes with its own stress, and then they have to deal with treatment. They should really have a clear picture of whether or not what was found in their breasts is good or bad before making those decisions.”

For the immediate future, however, Tamimi understands how these findings can create confusion for women over time. “It’s disappointing to people to hear that screening mammography isn’t the tool that it’s been presented as,” Tamimi says. “Dialogue about overdiagnosis is important to get out there so that research and developments don’t stay stagnant.”

Tamimi says the Norwegian study serves as a starting point for more effective communication between physicians and patients regarding over-diagnosis, which she contends goes hand in hand with misdiagnosis.

Lee points out that while this study brings up the issue of too much screening and the potential for overdiagnosis that might come with that, at the same time state and federal governments are debating the legislation of mandatory breast density notification. Texas, Connecticut, and Virginia passed laws within the last two years that require radiologists to notify patients if they have dense breast tissue following routine screening mammography; other states, as well as the federal government, are considering similar measures this year. There is the belief that legislating dense breast notification could lead to more screening with ultrasound, MRI, and other imaging modalities, which could lead to more false-positives.

“On the one hand we’re saying there are too many false-positives and too much screening,” Lee says. “On the other hand, there is the breast density notification issue that will likely lead to more screening. As breast imagers we’re caught between two imperatives: screen less vs. screen more.”

While Lee recognizes that mammography is not perfect, it is the only screening tool that has been shown to decrease mortality from breast cancer. “The bottom line is that screening mammography saves lives,” she says.

— Kathy Hardy is a freelance writer based in Phoenixville, Pennsylvania. She is a frequent contributor to Radiology Today.